Camp Clio 2015 Application  

Last name: First name: Gender:

Birthdate: Grade in Sept.

2015: Returning camper? yes / no

Age at camp: Family

address:

city state zip

One cabinmate request (must be mutual)

Parent 1 * info Parent 2 info Emergency contact 1 Emergency contact 2

Last name:

First name:

Home phone

Work phone

Cell phone

Email

Relationship

* primary contact for camper communications

Please choose All-Day or Residential camper and check the box for each session being requested

Sessions: All-Day Camp Sessions: Residential Camp

1 June 28 – July 4, 2015 1 June 28 – July 4, 2015

2 July 5 – July 11, 2015 2 July 5 – July 11, 2015

3 July 12 – July 17, 2015 3 July 12 – July 18, 2015

* Saturday stayovers: Saturday July 4, 2015

Saturday July 11, 2015

Saturday night stay is ONLY for campers living outside CT Please complete to calculate your total charges

number of Day sessions @ $ 400/week $

number of Residential sessions @ $550/week $

Leaders in Training Program (sessions 1,2,3) @ $ 1,350 $

Counselors in Training Program (sessions 2-5) @ $1,600 $

number of Saturday stayovers @ $50.00 $

Total $

($250 deposit for each week requested) Deposit $ ( )

Please choose Method of Payment

Balance $

Check # __________

to be paid at least 3 weeks prior to camper's arrival date

Money order

Credit card (attach authorization form)

Parent Questionaire/Release/Abuse & Neglect policy must be signed and returned along with this application  

Signature__________________________________________________________Date__________________________________  

Camp  Claire  2015  Parent  Questionnaire/Release/Abuse  &  Neglect  Policy      Camper’s  Name  _____________________________________      Nickname  __________________________    Please  complete  the  following  questions  to  help  us  give  your  child  the  best  possible  camp  experience.  This  information  will  only  be  shared  with  the  staff  that  need  to  know  and  with  the  best  interests  of  your  child  in  mind.         Has  your  child  been  to  camp  before?  __________________________________________________________     How  did  you  hear  of  Camp  Claire?            __________________________________________________________     Does  your  child  have  any  special  dietary  needs?  _________________________________________________     _________________________________________________________________________________________     What  are  you  hoping  for  your  child  to  gain  by  attending  camp?  ______________________________________     _________________________________________________________________________________________     _________________________________________________________________________________________  

Has  your  child  been  diagnosed  with  any  learning  disabilities,  emotional  or  behavior  problems,  or  are  there  any  concerns  camp  should  be  aware  of?  ____________________________________________________________  

  _________________________________________________________________________________________     _________________________________________________________________________________________      Releases:     May  your  child  participate  in  walks  near  camp  property?                    Yes          No  

May  your  child  participate  in  Camp  Claire  based  canoe  trips  on  the  Connecticut  River?          Yes          No     May  your  child  participate  in  Camp  Claire  Low  Challenge  Ropes  Course  activities?                    Yes          No     May  your  child  be  photographed  for  Camp  Claire/Camp  Clio  advertisements  or  camp  newspaper?            Yes          No     I  understand  that  if  my  child  engages  in  drug  use,  alcohol  use,  abusive  language,  inappropriate     sexual  behavior,  aggression  toward  another  person,  or  in  possession  of  firearms  or  fireworks,  

he/she  will  be  asked  to  leave  Camp  Claire  immediately  and  at  their  own  expense.                                                                Yes          No    

Parent  signature          _____________________________     Date  ________      

Abuse  and  Neglect  Policy:  You  have  entrusted  your  child/children’s  care  to  the  staff  of  Camp.  Claire.  We  are  committed  to  providing  the  best  

possible  and  most  appropriate  learning/fun  experiences  for  your  child/children.  Occasionally  there  are  factors  in  a  child’s  appearance  and  behavior  that  lead  to  suspicions  of  child  abuse  or  neglect.  Connecticut  law  requires  that  all  childcare  professionals,  including  all  staff  of  a  childcare  program/camp,  report  suspected  abuse  or  neglect  to  the  Department  of  Child  and  Families’  Child  Abuse  and  Neglect  Hotline  (1-­‐800-­‐842-­‐2288)  or  the  local  police  in  order  that  children  may  be  protected  from  harm  and  that  the  family  be  helped.    

Staff  are  mandated  reporters  and  have  been  instructed  to  report  suspected  incidents  of  child  abuse.  Failure  to  do  so  may  result  in  disciplinary  action  up  to  and  including  termination  of  employment.  

Should  you  have  difficulty  in  providing  for  your  child’s  emotional  and  physical  needs,  you  are  encouraged  to  ask  for  help.  Our  staff  can  help  you  in  finding  community  resources,  which  can  offer  assistance  to  your  family.  

Should  you  at  any  point  during  your  child’s  enrollment,  have  any  questions  or  concerns  about  your  child’s  care  or  safety,  we  encourage  you  to  speak  immediately  to  the  Director  or  contact  other  personnel.  

 I  have  read  and  understand  Camp  Claire’s  Abuse  and  Neglect  Policy.    

   Parent  signature          _____________________________     Date  ________  

   

       Camp  Clio  Questionnaire      What  size  t-­‐shirt  does  your  child  wear?    _____________________________________    How  did  you  hear  about  Camp  Clio?  _________________________________________    From  where  was  your  child  adopted?  _______________________________________    At  what  age  was  he/she  adopted?  ___________________________________________    Does  your  child  ask  for  help  when  needed?  _________________________________    If  not,  what  does  your  child  look  like  when  he/she  needs  help?    ___________________________________________________________________________________    ___________________________________________________________________________________      Does  your  child  have  any  fears?  ______________________________________________    ___________________________________________________________________________________    Does  your  child  have  any  sensory  issues  or  environmental  triggers?    ___________________________________________________________________________________    ___________________________________________________________________________________    What  support  does  your  child  need  to  have  a  successful  experience  at  camp?    ___________________________________________________________________________________    ___________________________________________________________________________________    ___________________________________________________________________________________  

         Camp  Clio  Scholarship  Application    ___________    I  would  like  to  apply  for  a  scholarship  to  Camp  Clio.  _____________    Does  your  child  receive  a  free  school  lunch?    Briefly  state  your  reason  for  applying  for  a  scholarship  and  send  it  with  your  application.    

 

  Camp  Claire  Credit  Card  Authorization  Form      Camp  Claire  offers  a  credit  card  payment  option  for  those  campers  wishing  to  use  a  credit  card  for  payment  rather  than  a  check.    The  following  provisions  apply  for  those  wishing  to  use  a  credit  card:  

1. Payment  in  full  is  required  at  the  time  of  application.  Not  a  deposit.  2. A  4%  fee  must  be  added  to  the  amount  due  to  cover  the  costs  of  credit  card  processing.  

   

Please  complete  the  following  if  credit  card  payment  is  requested:      Cost  of  session(s)  your  camper  is  registering  for  (from  the  application  form)                    $________________    4%  processing  fee  (multiply  the  amount  above  by  0.04)         +  $  ________________    Total  amount  to  be  charged  to  your  credit  card           =  $  ________________          

Credit  card  to  be  charged  (please  circle  one):      

American  Express      Discover            MasterCard     Visa      

Card  number                 _______________________________              Expiration  date         _______________________________  Security  code  (on  back  of  card)    _______________________________  

   

Name  as  it  appears  on  card       _______________________________    

Billing  address         _______________________________               _______________________________               _______________________________      

Signature  of  authorized  cardholder     _______________________________    Date           ____________________